Psychiatric disorders of childbirth

Psychiatric disorders of childbirth are mental disorders developed by the mother related to the delivery process itself. They overlap with the organic prepartum and postpartum psychoses and other psychiatric conditions associated with having children. Symptoms include rage, or in rare cases, neonaticide.[1]

There are many distinct forms of psychosis which start during pregnancy (prepartum) or after delivery (postpartum). In Europe and North America, only one – polymorphic psychosis (postpartum psychosis)– is commonly seen. Postpartum bipolar disorder, referred to in the DSM-5 as bipolar, peripartum onset, is a separate condition with no psychotic features. Historically, about one quarter of psychoses after childbirth were 'organic' and would now be classified as a form of delirium.[2] This means that a severe mental disturbance, usually in the form of delirium, develops as a complication of a somatic illness.[3]

Postpartum PTSD was first described in 1978.[4] Since then over 60 papers have been published. After excessively painful labours, or those with a disturbing loss of control, fear of stillbirth or complications requiring emergency Caesarean section, some mothers suffer nightmares, and intrusive images and memories ('flashbacks'), similar to those occurring after other harrowing experiences. They can last for months.[5] Some avoid further pregnancy (secondary tocophobia), and those who become pregnant again may experience a return of symptoms, especially in the last trimester. Rates up to 5.9% of deliveries have been reported.[6] There is some evidence that early counseling reduces these symptoms. Enduring symptoms require specific psychological treatment.

The word comes from the Greek tokos, meaning parturition. Early authors like Ideler[7] wrote about this fear, and, in 1937, Binder[8] drew attention to a group of women who sought sterilization because of tocophobia. In the last 40 years there have been a series of papers published mainly from Scandinavia. Tocophobia can be primary (before the first child is born) or secondary (typically after extremely traumatic deliveries). Elective Caesarean section is one solution, but psychotherapy can also help these women to give birth vaginally.[9]

Postpartum infective delirium was described by Hippocrates:[10] 8/17 female cases in the 1st and 3rd books of epidemics suffered from postpartum or post-abortion sepsis, all complicated by delirium. In Europe and North America the foundation of the metropolitan maternity hospitals, together with instrumental deliveries and the practice of attending necropsies, led to epidemics of streptococcal puerperal fever, resulting in maternal mortality rates up to 10%. The peak was about 1870, after which antisepsis and asepsis gradually brought them under control. These severe infections were often complicated by delirium, but it was not until the nosological advances of Chaslin[11] and Bonhöffer [12] that they could be distinguished from other causes of postpartum psychosis. Infective delirium hardly ever starts during pregnancy, and usually begins in the first postpartum week. The onset of sepsis and delirium are closely related, and the course parallels the infection, although about 20% of patients recover from the infection, but develop chronic confusional states. Recurrences after another pregnancy are rare.

A severe mental disorder was described by Wernicke [13] and Korsakoff.[14] Its most striking feature is loss of memory, which can be permanent. The cause is vitamin B1 (thiamine) deficiency, usually found in severe alcoholics. It can also result from pernicious vomiting of pregnancy (hyperemesis gravidarum). Over 125 cases have been reported in the world literature and, although thiamine treatment has been available since 1936,[15] these cases still occur in countries with advanced medical services, due to rehydration without vitamin supplements. A few patients have developed symptoms after the death of the foetus, miscarriage, termination of pregnancy or delivery.

Before the advent of antibiotics, streptococcal infections occasionally led to a condition called Chorea gravidarum. Chorea gravidarum, a severe variant of Sydenham's chorea, can have a number of psychiatric complications – character change, depression, Tourette's syndrome,[19] hypnogogic hallucinations,[20] defect states and acute psychosis.[21] But it still occurs as a result of systemic lupus or anti-phospholipid syndromes. Nevertheless, chorea psychoses are very rare, with only about 50 prepartum cases reported in the literature. Occasionally, they can break out after delivery, or after a termination of pregnancy.[22]

Puerperal women are liable to thrombosis, especially thrombophlebitis of the leg and pelvic veins. Aseptic thrombi can also form in the dural venous sinuses and the cerebral veins draining into them. Most patients present with headache, vomiting, seizures and focal signs such as hemiplegia or dysphasia, but a minority of cases have a psychiatric presentation.[24] The incidence is about 10/10,000 births in Europe and North America,[25] but much higher in India, where large series have been collected.[26]

Women with a lifelong epileptic history are also liable to psychoses during labour in the puerperium. Women occasionally develop epilepsy for the first time in relation to their first pregnancy, and psychotic episodes have been described.[30]

With the great improvement in obstetric care, severe complications of pregnancy and childbirth have become rare. There is, however, a great contrast between Europe, North America, Australia, Japan and some other countries with advanced medical care, and the rest of the world. The wealthiest nations produce only 10 million children each year, from a total of 135 million. They have a maternal mortality rate (MMR) of 6–20/100,000. Some poorer nations with high birth rates have an MMR more than 100 times as high,[31] and, presumably, a corresponding prevalence of severe morbidity. For example, in Sub-Saharan Africa, 21 nations, with a combined birth rate of over 14 millions, have an MMR >1,000/100,000. Only a minority of deliveries in sub-Saharan Africa and South Asia are attended by skilled personnel (doctors, nurses or midwives).[32] In Dar es Salaam, the majority of postpartum psychoses are organic.[33] In Africa, India & South East Asia, and Latin America, these organic disorders may still be as important as they have been throughout human history.